‘Almajiris’ are children and adolescents sent far away from their homes to study in Islamic schools under the care of Muslim scholars. Over the years, there has been a decline in the capacity of the scholars to cater to these pupils. Consequently, Almajiris spend significant periods of time on the streets begging and carrying out menial jobs to earn a living thereby increasing their risk for physical and mental disorders.
Trang 1RESEARCH ARTICLE
A comparative study of the prevalence
and correlates of psychiatric disorders
in Almajiris and public primary school pupils
in Zaria, Northwest Nigeria
Aishatu Abubakar‑Abdullateef1,2* , Babatunde Adedokun3 and Olayinka Omigbodun2,4
Abstract
Background: ‘Almajiris’ are children and adolescents sent far away from their homes to study in Islamic schools under
the care of Muslim scholars Over the years, there has been a decline in the capacity of the scholars to cater to these pupils Consequently, Almajiris spend significant periods of time on the streets begging and carrying out menial jobs
to earn a living thereby increasing their risk for physical and mental disorders The aim of this study was to compare the prevalence of psychiatric disorders among Almajiris and public primary school pupils in Zaria
Methods: A comparative cross‑sectional design was utilized to compare 213 Almajiris and 200 public primary school
children and adolescents aged between 5 and 19 years All participants were administered a Socio‑demographic questionnaire and the Schedule for Affective Disorders and Schizophrenia for School‑aged Children Present and Life‑ time Version (K‑SADS‑PL) Data were analyzed using Chi square tests and logistic regression
Results: The current prevalence of psychiatric disorders among Almajiris and public school pupils was 57.7 and
37.0% respectively After adjusting for age and family characteristics, Almajiris were significantly more likely to have any psychiatric diagnosis, depression, enuresis, substance use, and post traumatic stress disorder but less likely to have separation anxiety disorder than the public school pupils
Conclusion: Psychiatric disorders are more prevalent among Almajiris and public primary school pupils in Northwest
Nigeria than found in other prevalence studies with a significantly higher rate among the Almajiris Joint efforts need
to be made by the Government and Civil Society organizations including religious groups towards reforming the Almajiri education system and the provision of programmes aimed at reducing the prevalence of psychiatric disorders
in both Almajiris and the school pupils
Keywords: Almajiris, Street children, Mental health, Zaria, Northern Nigeria
© The Author(s) 2017 This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/ publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.
Background
Street children constitute an important social and
pub-lic health challenge in both developed and developing
countries of the World [53] They are a marginalized and
vulnerable group [55] and have been described by the
United Nations Children’s Fund (UNICEF) as “Excluded
and Invisible” This concept is in reference to their inabil-ity to access vital resources such as health care, food and education coupled with their omission from vital statis-tics such as birth and death registration This is despite their vulnerability to numerous physical and psychologi-cal hazards [53] Ironically, street children are physically visible, living and working on roads and in public areas Some of the health problems faced by street children include physical and sexual abuse, sexually transmitted infections, and psychoactive substance use [22]
Open Access
*Correspondence: aishateama@yahoo.com
1 Department of Psychiatry, Ahmadu Bello University Teaching Hospital
Zaria, Zaria, Nigeria
Full list of author information is available at the end of the article
Trang 2Street children in Nigeria, show cultural and
geo-graphic diversity In the Southern parts of Nigeria, they
are typically found as ‘street urchins’ or ‘area boys’ in
motor parks (stations where passengers board or
disem-bark from buses and taxis in their transit from one place
to another), hawking wares or food items, or engaged in
menial jobs to supplement family incomes or fend for
themselves [4 21, 34, 52] Some features of these
chil-dren include disrupted family backgrounds and poorly
educated parents with large families [4] In addition, for
those street children in school, academic performance is
usually poor and they are often unable to complete school
due to a number of factors including school truancy,
alcohol and drug abuse, having to earn some income for
themselves or their family and suspension from school
due to one misconduct or the other [41] Sexual abuse
[28], risky sexual behavior [43], and use of psychoactive
substance [37] have been reported among street children
in southern Nigeria
By contrast, in Northern Nigeria, street children are
identified as “Almajirai (singular Almajiri)”, found in
groups taking Quranic lessons from Mallams
(Ara-bic word for teachers), begging for alms, wandering the
streets, performing tedious and sometimes onerous jobs
in exchange for food or money [21, 34, 39] Quranic
schools have been an influential aspect of the early
childhood education in Northern Nigeria [17] They are
semi-formal centers of religious education in which male
children (females are rarely sent out) aged as young as
3 years are sent to Mallams faraway from their parents to
acquire Islamic knowledge and learn the Holy Book [50]
The word ‘Almajiri’ has its roots in the Arabic
lin-gua Its origins can be traced to the Arabic word
Al-Muhajirun, which means to emigrate [12] Traditionally,
the Mallams (Teachers) were responsible for the
feed-ing and upkeep of the Almajiris under their care [12,
32] They often had farms of various sizes, the harvest of
which was usually enough to feed their families and the
Almajiris under their care Where this was not the case,
they supplemented with gifts received from members of
the community These were not in shortage due to the
respect and high esteem with which Mallams are held In
recent times however, rapid urbanization and a shift from
agrarian culture have brought this means of sustenance
to a decline mainly through the routes of poverty and
scarcity of resources
In Hausa land, the term ‘Almajiri’ has evolved over time
and in current parlance could refer to one of three
cat-egories of children: Children sent from their homes and
entrusted to the care of Mallams to study the Quran;
those who roam on the streets for the purpose of getting
alms; and children that engage in some form of labour to
earn a living [2 8 12] Almajiris invited to participate in
this study were children who had left home to study the Quran and are currently under the care of a Mallam The social profile of Almajiris includes many factors that in the long term predispose them to mental health problems For example, they find themselves in peculiar circumstances, lacking the protection of secure family relationships having been separated from their parents
as early as 3 years of age [1] Furthermore these children usually go hungry, engage in hazardous and odd jobs
in exchange for food, and are exposed to the elements
on the streets This in combination with poor physical health, lack of supervision while roaming the streets beg-ging, and conditions of overcrowding at the Tsangayas (Quranic schools) places them at an increased risk of abuse, conditions such as anxiety, depression, post trau-matic stress disorder and behavioral problems [13] Notably however, the health of the Almajiris has received relatively little attention The majority of exist-ing studies and reports have focused on the educational reform of the Almajiri school system Perhaps the only recent study that examined an aspect of the mental health
of this group is that by Abdulmalik et al which found a prevalence of psychoactive substance use of 66% [1] In comparison to the situation in developing countries, the mental health of street youths has been the focus of sev-eral studies in the developed world These studies have reported proportions above 80% for psychiatric disorders among homeless youth [26, 45] Comparative studies such as those by Slesnick et al and Kamieniecki showed twice the lifetime prevalence of psychiatric illness among homeless youth when compared with comparable con-trols in homes [30, 47] Additionally, depression [36, 56] and disruptive behavior disorders [35] were significantly commoner among the homeless
The few studies on psychopathology of homeless or street children in developing countries include a Turkish study [48] that found 61% of street children had at least one psychiatric disorder while a Ghanaian study reported that as high as 87% of homeless youth showed moder-ate to severe psychosocial symptoms [9] In their study which assessed 112 Burundian male children, Crom-bach et al provide evidence that psychopathology among children who had spent parts of their lives on the streets was associated with exposure to violence [19] A recent review [22] identified physical abuse, sexual abuse, paren-tal conflict, parenparen-tal psychiatric disorder, substance use, family support and neighborhood disorganization as risk factors for psychiatric disorders Oppong Asante found that youth’s resilience, stigma, violent behavior and sui-cidal ideation were associated with emotional problems among homeless youth [9]
The spectrum of mental health problems among this special class of street children, the Almajiris, is the focus
Trang 3of this study The objective of this study is to determine
the prevalence of psychiatric disorders among Almajiris
and compare this with children in formal schools
Methods
Location and participants
The study was done in Zaria, a major city in Kaduna
state, North-west Nigeria It is one of the oldest towns
in Northern Nigeria According to the 2006 National
Census the population of Zaria stands at 406, 990 [38]
Statistics available in 2008 for Kaduna State show a Net
Basic Education enrollment ratio of 54%, which is 9
points below the national average It is higher for primary
schools but a remarkable decline becomes apparent as
the level of education increases, such as at senior
second-ary school level, where enrollment is 24% In a census
of all schools in Kaduna state, there were 5108 Quranic
schools in the state with Zaria Local Government Area
(LGA) accounting for 547 of these schools Total
enrol-ment in the Quranic schools in Zaria is 33,763 (Kaduna
State Ministry of Education Nigeria: Education Sector
Analysis [29]
Zaria, fondly known as Zazzau was founded by a
leg-endary warrior known as Queen Amina around the
fif-teenth to sixfif-teenth century The city is accessible by rail
owing to its location on a major North–South railroad,
by road through the federal highway and by air through
the facilities at the Nigerian College of Aviation
Technol-ogy (NCAT) located in the city centre The main
occupa-tion of the Zaria populace is agriculture, but they engage
in other activities such as embroidering ceremonial
dresses It is one of the nation’s leading producers of
ton for export and is the main ginning centre for the
cot-ton grown in the northern Nigerian region Zaria has a
long entrenched reputation for being a centre of Islamic
knowledge, making it befitting for this study Since the
nineteenth century, it has attracted pupils from all over
the North of Nigeria and neighboring countries such
as Niger, Mali, Cameroon and Chad for the purpose of
learning and memorizing the Quran
This was a comparative cross-sectional study
evaluat-ing mental health problems among Almajiris and
pub-lic primary school pupils Ethical approval was granted
by the Health Research Ethics Committee (HREC) of
the Kaduna State Ministry of Health before onset of the
study On account of the remote and sometimes scattered
backgrounds of the Almajiris, obtaining parental consent
would have been practically impossible Due to these
dif-ficulties, a waiver of parental consent was sought for and
granted by the committee granting ethical approval based
on the principle of “no greater than minimal risk” to the
participants Permission was obtained from the Kaduna
State Bureau for Religious Affairs (Islamic Matters) and
the Kaduna State Ministry of Education to interview Almajiris and public primary school pupils respectively For the purpose of this study, the guardian of an Alma-jiri was considered to be the Mallam under whose care
he was All Almajiris aged 5–19 years in the selected Quranic schools who assented and whose guardian gave informed consent for them to participate in the study were included The comparison group comprised an equal number of assenting pupils selected from nearby public primary schools whose parents or guardian gave informed consent for their inclusion in the study Par-ticipants signed or thumb printed an assent form if they were less than 18 years and a consent form if they were
18 years or older Consent forms were made available to parents and guardians of public school pupils to peruse two days to commencement of the study Signature or thumbprint appended to these forms indicated consent for the child or ward to be interviewed
One public school pupil who had gross features of intellectual deficiency was excluded from the study due
to inability to understand the questions He was replaced with another pupil selected at random from the sample frame All other participants were proficient in either English or Hausa
Sample size and sampling procedures
The minimum number of children studied was deter-mined assuming a 5% chance of Type 1 error, 80% power and 10% non-response rate Assuming a 15% difference between the two populations and 66% as an estimate of psychoactive substance use from a previous study [1],
182 children was determined to be minimum sample size 213 Almajiris and 200 children in public schools were eventually studied
A multistage sampling method was employed for selec-tion of participants in the two groups For the Almajiris, Zaria was divided into wards and from this sample frame
3 wards were randomly selected for the study in the first stage In the second stage, all Almajiri schools in the selected wards were identified and one was selected from each through ballot Though the proposed minimum sample size was 182 per group, there were 213 Alma-jiris between the ages of 5 and 19 in the three selected schools (85, 58 and 70 Almajiris respectively) and all of them were interviewed For Almajiri pupils whose age could not be readily identified, the Mallams and older pupils assisted the interviewers in age estimation by ask-ing simple questions such as how old they were when they left home and how many years they had spent at Almajiri school This was done in a bid to ensure they fell within the age range for inclusion into the study Mallams
in the Quranic schools gave permission for their pupils
to be interviewed only during the weekends (Saturdays
Trang 4and Sundays) so as to reduce disruption to their
off-school days which are usually observed on Thursdays and
Fridays
Concerning selection of children in the public schools,
a list of schools in the selected wards was obtained
from the Zaria Local Government Education
Author-ity, three of which were then selected: Adamu Dikko,
Bashir Adamu and Tsoho Abdullahi Local Education
Authority (LEA) Schools The comparison group was
selected such that each LEA school was closest to the
Almajiri School studied Seventy-two male pupils were
selected for participation from each school, as all the
three schools selected had roughly the same number of
children enrolled Class registers containing the names
and gender of pupils in Primaries 1–6 were obtained and
12 male pupils randomly selected per level thus reaching
the required total of 72 pupils Interviews in the primary
schools were carried out on three separate working days
spanning 2 weeks Public primary schools were chosen as
a comparison to factor in as closely as possible, the same
socio-economic circumstances
Materials
Two main instruments were used for data collection: a
socio-demographic characteristics questionnaire adapted
from the Global School-based Health Survey (GSHS)
Nigeria Questionnaire and the Schedule for Affective
Disorders and Schizophrenia for School aged
Children-Present and Lifetime Version (K-SADS-PL) The
Socio-Demographic Questionnaire was employed to gather
relevant information about the participants and their
family characteristics It had three sections with the first
section obtaining information about age, religion,
nation-ality and state of origin The second section obtained
information about the family background of the
par-ticipants including family type (monogamous or
polyga-mous), parents’ marital status, family size and parents’
level of education while the third section was specific to
the Almajiris and included questions on age at first
leav-ing home for Quranic school, their source of income,
meals and where they slept Variables assessing if
par-ticipants had sustained injury, being in a physical fight or
being bullied (all in the 12 months preceding study) were
included in this section and had been adapted from the
GSHS-Nigeria
The K-SADS-PL is a semi-structured diagnostic
inter-view for children [31] It is designed to assess current
and past episodes of psychopathology in children and
young persons according to the third and fourth edition
of the Diagnostic and Statistical Manual of Mental
Dis-orders (DSM-III-R and DSM-IV) criteria Though the
K-SADS-PL interview includes additional information
obtained from the parents, for the purpose of this study,
it was administered on the participants only This was
in view of the difficulties that would have been encoun-tered with attempting to trace parents of the participants especially the Almajiris The K-SADS-PL is divided into two parts, the Screen Interview and Diagnostic Supple-ments The Screen Interview evaluates for primary symp-toms of the different diagnosis groups Sympsymp-toms in the screen Interview are rated for current and most severe past Symptoms are rated negative for current and past episode if the child has never experienced them Affirma-tive answers are further probed as to when those symp-toms were present and rated accordingly The Diagnostic Supplement has a list of probes and criteria to assess for current or lifetime history of psychiatric disorders The K-SADS-PL assesses exposure to traumatic events
as part of the screen for Post-Traumatic Stress Disorder The instrument, upon completion of its administration yields a definitive psychiatric diagnosis Participants who had significant symptoms on application of the screen interview were then taken through the corresponding diagnostic supplements for confirmation The
K-SADS-PL probes were extracted into a separate document for ease of translation and administration All instruments used in the study were translated to Hausa using the back-translation method by a psychiatrist and linguist with proficiency in English and Hausa The instruments were first translated into Hausa by a Hausa linguist and subsequently, an independent psychiatrist who was blind
to the original instrument translated this Hausa version back to its original language, English The original and the newly translated English versions were then com-pared by the authors Any inaccuracies and mistransla-tions were made known to the Hausa linguist who made
a fresh translation of the problematic question to Hausa and the independent psychiatrist translated this to Eng-lish This process was repeated until the newly translated English version came as close as possible to the original document
Four research assistants were trained on the adminis-tration of the socio-demographic questionnaire while the author, AA administered the K-SADS-PL which is designed to be used by trained clinicians Each item and its alternative were read out to the child in Hausa or Eng-lish depending on his preferences, options chosen by the participant were then marked on the instrument by the author or research assistant Almajiris were interviewed
in their Quranic schools The Zaure, (a large
ante-cham-ber in traditional Hausa architecture) was made available
to the interviewers for use in these schools In the first two public primary schools visited, empty classrooms were cleaned and set-up for the interviews, while in the third school, the interviews were conducted in the school library One pupil was interviewed at a time, in an area
Trang 5away from the others, to ensure a maximum level of
pri-vacy and confidentiality There were no names or
iden-tification markers on the questionnaires so as to ensure
anonymity
Data analysis
Data collected were analyzed using the Statistical
Package for Social Sciences (SPSS) software version
21 (SPSS-21) Comparison of categorical variables
such as respondents’ socio-demographic
characteris-tics and psychiatric diagnosis between the two groups
were tested using Chi square and Fisher’s exact tests
The mean number of traumatic events was compared
between the groups using the independent samples t
test Univariate logistic regression analyses were
car-ried out to estimate odds ratios comparing
psychiat-ric diagnoses between Almajiris and children in public
schools Adjustments for age, family type, marital status
of parents, father and mother’s education, and number
of parents’ children were made in multivariable logistic
regression analyses for selected psychiatric diagnoses
(based on an appreciable number of children that had
those conditions) including study group (Almajiri
ver-sus public school children) as the main independent
variable Crude and adjusted odds ratios (ORs) and their
95% confidence intervals were reported for univariate
and multivariable logistic regressions respectively
Hos-mer–Lemeshow goodness of fit tests was used to assess
model fit Level of significance was at 5%
Results
Demographic information of participants
A total of 213 Almajiris and 200 public school pupils
were involved in the study The mean age of the
Alma-jiris in years was significantly higher than that of
pub-lic school pupils (13.1 ± 3.5 vs 10.9 ± 2.9, t = −6.69,
df = 411, p < 0.001, 95% CI −2.90 to −1.58) All the
par-ticipants indicated that their family religion was Islam
About a quarter (25.8%) of participants in the Almajiri
group indicated they were non-Nigerian, compared to 3%
of the public school pupils All the non-Nigerians were
from Niger Republic which borders Nigeria to its North
All other participants indicated they were from
North-ern parts of Nigeria although a significantly higher
pro-portion of Almajiris than public school pupils (19.5% vs
4.2%) hailed from the North-Central region which is
out-side the region where the study was conducted
Table 1 shows the distribution of selected
characteris-tics of Almajiris and the public school pupils
Almajiri pupils had a significantly higher proportion
coming from polygamous homes, and had fathers and
mothers with lower education than public school
par-ticipants The two groups were not significantly different
concerning marital status of parents, number of mother’s
or father’s children
Traumatic events among participants
Table 2 shows that more Almajiris reported having ever been involved in a car accident, ever witnessed an acci-dent and ever been physically abused The mean num-ber of traumatic events was significantly higher among Almajiris (1.38, SD = 1.05) compared to public school pupils (mean = 0.87, SD = 0.83) (p < 0.001)
Prevalence and pattern of psychiatric diagnosis
The differences in psychiatric diagnosis on K-SADS-PL between the two groups of children are shown in Table 3
A significantly higher proportion of Almajiris (57.7%) had
an identifiable diagnosis on the K-SADS-PL compared
to their public school counterparts (37.0%, p < 0.001) Concerning specific conditions, a higher proportion of Almajiris compared to their public school counterparts met the criteria for a diagnosis of depression, general-ized anxiety disorder, enuresis, substance use and post traumatic stress disorder However public school pupils were significantly more likely than Almajiris to meet the diagnosis for Separation Anxiety and Obsessive Compul-sive Disorders No significant differences were noted in the prevalence of mania, psychosis, social phobia, panic attacks, agoraphobia, encopresis, attention deficit hyper-activity disorder (ADHD), oppositional defiant disorder, and conduct disorder None of the participants met the criteria for Anorexia Nervosa or Bulimia Nervosa Logis-tic regression analysis was done for those diagnoses with
a sizeable number of participants with the condition in both groups
As shown in Table 3, the adjusted odds of the diag-nosis of depression, enuresis, substance use and PTSD remained significantly higher among Almajiris while separation anxiety was significantly more likely among public school children The adjusted odds ratio for Gen-eralized Anxiety Disorder was however not significant
Correlates of psychiatric diagnosis
Variables found to be significantly associated with an Almajiri having a psychiatric diagnosis on the
K-SADS-PL on bivariate analysis are shown in Table 4 These were mother’s highest level of education, having to go hungry, sustaining serious injury, involvement in a physical fight, being bullied in the last 30 days and visiting home less than three times a year
Discussion
This study has shown that overall, psychiatric diagnoses were more common among Almajiris using the
K-SADS-PL Additionally, diagnoses of depression, enuresis,
Trang 6Table 1 Comparison of selected socio-demographic characteristics of Almajiris and the public school pupils
Figures in italics indicate significant values
Variable Almajiris N = 213 (%) Public school pupils N = 200 (%) χ 2 p value
Age in 5 year categories
Family type
Marital status of parents
Father’s children
Mother’s children
Father’s level of education
Mother’s level of education
Table 2 Exposure to Traumatic Events among Participants (N = 413)
Figures in italics indicate significant values
* Indicates Fisher’s exact statistic
a Including motorcycle and bicycle accidents
Traumatic event Almajiris Public school pupils χ 2 p value
N = 213 frequency (%) N = 200 frequency (%)
Trang 7Table 3 Bivariate and multivariable comparisons of psychiatric diagnoses on K-SADS-PL between Almajiris and public school pupils
K-SADS-PL diagnosis Crosstabs Univariate logistic regression Multiple logistic regression
% with diagnosis p** Crude OR (95% CI) Adjusted OR*** (95% CI)
Any condition
Public school pupils 73 (37)
Depression
Public school pupils 16 (8.1)
Mania
Public school pupils 2 (1.0)
Psychosis
Public school pupils 0 (0.0)
Panic attacks
Public school pupils 4 (2.0)
Separation anxiety
Public school pupils 28 (14.0)
Social phobia
Public school pupils 5 (2.5)
Agoraphobia
Public school pupils 6 (3.0)
GAD
Public school pupils 16 (8.1)
OCD
Public school pupils 5 (2.5)
Enuresis
Public school pupils 22 (11.1)
Encopresis
Public school pupils 1 (0.5)
ADHD
Public school pupils 6 (3.0)
ODD
Public school pupils 3 (1.4)
Conduct disorder
Public school pupils 1 (0.5)
Trang 8substance use, and PTSD were more likely and separation
anxiety less likely among Almajiris compared to public
school pupils To our knowledge this is one of the very
few sub-Saharan African studies studying the mental
health of street children Most noteworthy, this study has
focused on a special group of street children attending
Islamic schools in sub-Saharan Arica Our study provides information about the health of this group of children, an area that has been accorded little attention
The proportion of participants having any mental health problems among the Almajiri and public school pupils (57.7 and 37% respectively) are much higher than
11 4% seen in a primary care unit in Ilorin, North cen-tral Nigeria [51] and 20% in a similar clinic in South West Nigeria [25] This could be attributed to difference
in study populations However, studies of street children
in developing countries such as in Ghana [9] and Turkey [48] have reported similar high rates of psychiatric mor-bidity of 87 and 61% respectively
Almajiris had significantly higher odds of depression, enuresis, substance use and post traumatic stress disor-der than public school pupils after adjusting for age and some family characteristics Almajiris typically live a life
of uncertainty, they are not sure where the next meal will come from, they lack the basic necessities of life and overall their socio-economic circumstances are per-vasively dire They are also exposed to stressors such as traumatic events more often than other children How-ever, when we adjusted for exposure to traumatic events
in the logistic regression model of depression on study group (not shown in the results), the higher odds still remained The cross sectional nature of the data makes conclusions about the interrelationships between these variables difficult
A higher prevalence of depression and Post Traumatic Stress Disorder has similarly been reported amongst homeless adolescents [13] Depression has also been shown to be higher among homeless children in a US study compared to controls [36] A previous study of major depressive disorder among male adolescents in a
Table 3 continued
K-SADS-PL diagnosis Crosstabs Univariate logistic regression Multiple logistic regression
% with diagnosis p** Crude OR (95% CI) Adjusted OR*** (95% CI)
Tic disorders
Public school pupils 1 (0.5)
Substance use
Public school pupils 2 (1.0)
PTSD
Public school pupils 8 (4.0)
Figures in italics indicate significant values
* Based on Fisher’s Exact tests
** Based on Chi square tests; 213 Almajiris and 198 public school pupils included in the cross‑tabulations
*** Adjusted for age, family type, education of father, educational level of mother, number of mother’s children, number of father’s children, number of mother’
Table 4 Correlates of Psychiatric Diagnosis among
Alma-jiris (N = 213)
Figures in italics indicate significant values
Variable Psychiatric diagnosis
on K-SADS-PL χ
2 p value Yes frequency % No frequency %
Mother’s education
None 32 (72.7) 12 (27.3) 6.289 0.043
Quranic 85 (55.6) 68 (44.4)
Some formal
education 6 (40.0) 9 (60.0)
Often goes hungry
Yes 84 (64.1) 47 (35.9) 5.244 0.022
No 39 (48.1) 42 (51.9)
Sustained injury
Yes 69 (67.0) 34 (33.0) 7.312 0.007
No 53 (48.6) 56 (51.4)
Involved in a physical fight
Yes 68 (65.4) 36 (34.6) 5.133 0.023
No 54 (50.0) 54 (50.0)
Bullied in the last 30 days
Yes 75 (65.8) 39 (34.2) 6.503 0.011
No 48 (48.5) 51 (51.5)
Child visited parents in the last 12 months
<3 times 103 (74.6) 35 (25.4) 47.74 <0.001
3 or more times 18 (25.0) 54 (75.0)
Trang 9Nigerian secondary school reported values of 5.5% which
is close to the prevalence of 8.1% found among public
school pupils in our study [6]
The prevalence of substance use among Almajiris of
5.6% found in our study differs from that which
Abdul-malik and colleagues found five years previously in North
East Nigeria where 66.6% of Almajiris were engaged in
the use of a psychoactive substance [1] While this may
be a reflection of the true situation, it may be partly
explained by differences in the focus of study and
meth-odology The study by Abdulmalik et al assessed
Alma-jiris solely for psychoactive substance use using the
Global School-Based Health Survey (GSHS)
Question-naire and the WHO Student Drug Use QuestionQuestion-naire
which has been validated for use among Nigerian
stu-dents [3] It is thus possible the instruments were more
sensitive in picking up drug use than the K-SADS-PL
The occurrence of behavioral problems including
oppo-sitional defiant disorder, conduct disorder and ADHD
were strikingly low Only one Almajiri (0.5%) met the
criteria for a diagnosis of conduct disorder This is lower
than 4.2% reported among secondary school adolescents
in Northwest Nigeria [11] It is also lower than 6.1%
reported by Gureje et al and 9.3% by Adewuya in
South-west Nigeria [5 25] Also, previous studies have shown
significantly higher occurrence of disruptive behaviours
among homeless children compared to those living in
homes [35, 56] The relatively low rates of behavioural
disorders may be due to the reliance of this study on
self-reports rather than parent, teacher or peer evaluations
Observations have shown that children are better at
dis-closing their internalizing problems while externalizing
behaviours are better picked up by reports from parents,
teachers or peers
Public school pupils were about eight times more
likely to have separation anxiety than Almajiris About
14% of the public school pupils in this study had
sepa-ration anxiety, much higher than the 2.1% from a
pre-vious study among Nigerian in-school adolescents in
Southwest Nigeria [6] This finding could be explained
by the recent tide of insurgency in the Northern parts
of Nigeria In the immediate vicinity where the study
was conducted, there have been three bomb blasts in
the last 2 years and about 3 other such blasts in the
capital city, Kaduna which is about 80 km away from
the study site [7 49] There have also been a number
of killings and kidnappings of notable people in the
same areas [20, 44, 46] The Islamic sect ‘Boko Haram’
which operates in Northern Nigeria has recently waged
war against any form of Western style education,
some-times killing male students found in formal schools
[14, 24] or abducting girls in such schools [15]
Fur-ther studies are required to investigate the effects of
the insurgency on school children, so that appropriate mental health interventions can be offered to children attending formal schools in the Northern part of the country An explanation for the comparatively lower diagnosis of separation anxiety among Almajiris is that these children have been separated from their fami-lies, some from as early as 3 years of age, thus they are unlikely to have the levels of attachment requisite for the development of separation anxiety These high rates
of separation anxiety among public school pupils have ominous implications for child education in a region with low literacy levels
There were higher odds of exposure to traumatic events, accidents and disaster among Almajiris compared
to public school pupils The reason may be due to the sig-nificant periods spent by the Almajiris on the streets beg-ging for a livelihood, more often than not unaccompanied
by any adult, and are thus more likely to be involved in or witness such events Traumatic events have been linked with depressive symptoms in studies conducted in Nige-ria and a higher likelihood of developing these symp-toms was noted if the event directly affected the child [42] This could also explain the high rates of depression found among the Almajiris The higher reports of physi-cal abuse experienced by Almajiris is consistent with risks associated with their source of income and meals, where some of them are engaged in paid work in some households [23] Corporal punishment is also commonly practiced as a means of discipline in Quranic schools, and overall religious and cultural beliefs may encourage the use of force as a corrective measure in children [42] Mothers of Almajiris had lower levels of formal edu-cation than those of public school pupils Dating back
to the time when the country had regional govern-ments, the Western Region provided free education for its people but this was not replicated in the North In the North, much emphasis was placed on Quranic and Arabic education and has been postulated as a reason for the perpetuation of the Almajiri system of education
in its current state in previous studies [23] There was a higher likelihood to go hungry among Almajiris This has huge implications for their physical and mental health Nutrients derived from food are necessary for the pro-liferation of cells and tissues in the body which lead to visible growth The brain experiences rapid proliferation during childhood [33], and at the same time, fundamen-tal cognitive and interpersonal skills are being acquired The child’s vocabulary, problem solving skills, attention and motor coordination all increase significantly dur-ing this period Thus there is a likelihood of malnutrition and attendant risks of poor cognitive development where nutrition is inadequate either in terms of the quantity or quality [10, 16, 18]
Trang 10Approximately half of the Almajiris reported being
bul-lied in the previous month Almajiris are often perceived
in the society with negative connotations such as
‘mis-creants’, ‘dirty children’ and frequently chased away by
adults Earlier reports have highlighted how they suffer
stigma and hostility from pupils of public schools
dur-ing attempts at integrated education [27, 54] About half
of them had not visited their parents or guardians in the
last 12 months Leaving the protective family enclosure
at their formative years, coupled with the lack of care
and supervision encountered in the Quranic schools and
diminished parent–child interaction is likely to
exacer-bate the vulnerability of these young children
Some differences in the socio-demographic and family
characteristics of the two groups studied deserve
com-ments The finding of older children in Almajiri schools
is not unusual as the Almajiri system of education is an
unstructured program with graduation dependent on
a complete grasp of the Holy Quran This means that
sometimes the period of tutelage may extend for many
years [40] Notably, a modest proportion of Almajiris
couldn’t tell their ages spontaneously compared to the
public school pupils For such Almajiris, their ages had
to be deduced by some extrapolations such as adding
the number of years they had been at Almajiri School to
their age at leaving home Though their ages were
eventu-ally deduced, for the purpose of analysis they were left to
constitute the group which didn’t know their ages This
was borne out of the authors’ belief that it was a
possi-ble indication of reduced parent–child interaction among
the Almajiris It is expected that a child who lives with or
maintains adequate interaction with his parents would at
one time or the other be made aware of his age
Limitations
This study has some limitations First is the issue of
the appropriateness of the comparison group Several
characteristics such as family background are different
between the two groups making comparability difficult
However we adjusted for selected family characteristics
in a multiple logistic regression model Secondly, some
variables previously reported to influence the risk of
psy-chiatric disorders such as history of mental illness and
substance use were not collected due to difficulty in
get-ting access to the parents of the Almajiris These parents’
characteristics would have been adjusted for on the
mul-tiple regression model Thirdly the exclusion of Almajiris
that couldn’t understand the questions could influence
the prevalence of psychiatric diagnoses if those excluded
had characteristics that could predispose them to
psychi-atric disorders
A fourth limitation is the cross-sectional nature of
this study that limits the understanding of relationships
between the prevalence of psychiatric morbidity and factors such as family characteristics Longitudinal studies are needed that will enroll Almajiris from the point of departure from their families through time spent on the streets Finally, data was collected through self-reports, as caregivers and parents were not avail-able to provide an alternative source of information for the Almajiris, thus the reported rates for seemingly negative attributes such as behavioral problems (oppo-sitional defiant disorder, conduct disorder, attention deficit hyperactivity disorder and substance abuse) in this population may not be a true estimate Also, due
to multiple significance testing, there is the chance
of inflated type 1 errors, and larger p values should be interpreted with caution
Conclusion
The findings from this study indicate that the prevalence
of psychiatric disorders among Almajiris was higher than in the public school population Depression, Enu-resis, Substance Use and Post Traumatic Stress Disorder were higher in Almajiris than public school pupils The dire living circumstances of the Almajiris require earnest and resolute efforts towards improving their socio-eco-nomic status and providing them with formal educa-tion Attempts at reforming the Almajiri schools by the Government should be supplemented with measures to promote physical and mental health, including general health education, screening, early detection and manage-ment of pupils at risk of developing psychiatric disorders Leaving the protective family unit and diminished par-ent–child interaction is likely to exacerbate the vulner-ability of these young children, thus the current practice where they are discouraged from visiting home should
be abolished in order to help them maintain a secure and nurturing bond with their families
Abbreviations
K‑SADS‑PL: Schedule for Affective Disorders and Schizophrenia for School‑ aged Children‑Present and Lifetime Version; UNICEF: United Nations Children’s Fund; LEA: Local Education Authority; DSM‑IIIR: Diagnostic Statistical Manual Third Revision; DSM‑IV: Diagnostic Statistical Manual Fourth Version; ADHD: Attention Deficit Hyperactivity Disorder; PTSD: Post Traumatic Stress Disorder; GSHS: Global School‑Based Health Survey; GAD: Generalised Anxiety Disorder; OCD: Obsessive Compulsive Disorder; ODD: oppositional defiant disorder.
Authors’ contributions
All authors contributed to the conception and design of the study AA, BA and
OO were involved in writing and revision of the manuscript All authors read and approved the final manuscript.
Author details
1 Department of Psychiatry, Ahmadu Bello University Teaching Hospital Zaria, Zaria, Nigeria 2 Centre for Child and Adolescent Mental Health, University
of Ibadan, Ibadan, Nigeria 3 Department of Epidemiology and Medical Statis‑ tics, College of Medicine, University of Ibadan, Ibadan, Nigeria 4 Department
of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria